Patient Information

Phone Numbers & Contact Information

Is there anyone you would like to list that can have access to your personal health information? If so, please list below:

Name

Phone #

Name

Phone #

Lifestyle Questions

Do you....(check "yes" or "no") *

Yes

No

...use a computer or smartphone?

Yes

No

...enjoy hunting, fishing or shooting sports?

Yes

No

...hve a backup pair of eyeglasses?

Yes

No

...have a skin reaction to nickel or costume jewelry?

Yes

No

...have interest in trying contact lenses?

Yes

No

...have fluctuating vision problems that improve when you blink?

Yes

No

...have a separate pair of sunglasses?

Yes

No

...want to consider new glasses today?

Yes

No

Assignment & Release of Benefits/Privacy Notice

I acknowledge that I have been given the opportunity to review Eye Health Solutions Notice of Privacy Practices.

Name

Date

By entering your name and date in the above fields, you are digitally signing this document.

I, the undersigned, cerifty that I (or my dependent) have the insurance coverage with the company named below and assign directly to Eye Health Solutions all insurance benefits, if any, otherwise payable benefits for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Eye Health Solutions to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Insurance Coverage Company

Name

Date

By entering your name and date in the above fields, you are digitally signing this document.